All medical institutions, regardless of size and areas of expertise, prepare, send, receive, and post medical insurance claims. This process over the past few years has become so complex with changing laws and regulations that, in order to efficiently run a medical practice or institution, it has become necessary to computerize records and the billing process.
Nearly all medical practices, hospitals, clinics, and other medical institutions that have computerized their patient records have available to them, through the vendor that supplied their medical software system, an Electronics Claims Submission system to submit their medical claims to various insurance companies, such as Medicare and Blue Cross Blue Shield. The method of submission of insurance claims is either by transmitting the claim over the telephone line via a modem, or by placing the insurance claim on a magnetic tape and either mailing or delivering the tape to the insurance company. The above practices are now widespread in submitting claims.
Regardless of the method of claim submission, after the claim has been processed by the insurance company, the insurance company in nearly all cases prints its determination of the claim and mails it back to the medical provider. At this point, it is then necessary for the provider's staff to manually enter into their records the claim determination shown on the returned claim form, using their knowledge of claim interpretation and how their particular medical system processes claims. This final step is costly, prone to human error, and time consuming.
The only exception to this method of claim return is the transfer of claim determination via a telephone line data link or tape to tape transfer. These methods are highly costly and require highly specialized software to operate and are not affordable by most practices, clinics, or hospitals.
To date, there are two experimental methods for automated claim posting of insurance forms that are available to an extremely limited number of medical offices and institutions scattered in various states from two insurance companies. In the first method, the insurance company will post its determination of the insurance claim directly to the provider's medical system over the telephone line via a modem. In this method, the medical institution must have absolute faith that the insurance company will post the proper amount and pay the proper amount. They must also give up all control of their medical system and remove all security from their medical system to accommodate the insurance company. The medical office or institution must also be running only the specific medical software package that the insurance company's software can talk to. These disadvantages make this system not workable.
In the second method, the insurance company will transfer its determination onto a magnetic tape to be loaded into the provider's medical system directly. It suffers again from lack of control over the data being entered, lack of security over the medical system, requires a specific medical package to be used by the medical office or institutions, and entails excessive cost.
Consequently, because these are the only available methods to any medical office or institutions for an electronic claims reception, a substantial number use the manual keyboard entry method.
Most medical offices, clinics and hospitals have a computer system interconnected with either a single terminal or a plurality of local and/or remote terminals. These medical offices, clinics and hospitals already have purchased and are using one of several dozen medical software systems on their computer to maintain patient records, billing, accounting, etc. Because of their already committed assets and training in their medical hardware and software systems, they are mostly unwilling to accept systems such as the ones outlined by Pritchard (U.S. Pat. No 4,491,725) and Barber (U.S. Pat. No. 4,858,121) which, when operated most efficiently, provide nearly instant transmission and reception of claims after being processed by the insurance carrier, over the telephone line. They are unwilling to accept systems that require that they discard all their hardware and software systems previously purchased and in use.
Many medical offices, clinics, and hospitals have a computerized medical system which stores patient data, processes insurance claims and maintains charts and business accounting records. Of these tasks, insurance claim processing is the most difficult and complex for any system. There are presently hundreds of such medical systems in use and available. Each medical system performs basically the same functions but with a different hardware and software implementation. In practice, it is therefore difficult, and impossible in many cases, to transfer data from one medical system to another. It is generally impossible to obtain an add-on function to an existing medical system unless it was specifically written by the particular medical system manufacturer.
Since the most complex task is in the processing of insurance claims, many of these medical system manufacturers have developed and made available to their system purchasers an add-on to electronically transmit, via telephone lines, insurance claims to the two largest claim carriers, namely Medicare and Blue Cross Blue Shield. Claim submission to any of the hundreds of other insurance companies is handled by printing the claim and mailing it to the appropriate insurance carrier. This add-on package, however, does not provide the electronic reception by the medical center of the processed claim from the insurance company. The processed claim is still received by the medical center through the mail in paper form and posted manually.